Practical insights into schizophrenia treatment: Case studies highlight effective strategies

Explore the insights of Dr Pravesh Kassen, a dedicated psychiatrist specialising in schizophrenia treatment at Akeso Clinic in Pietermaritzburg, KwaZulu-Natal, as he shares two illuminating case studies.

Case Study #1

Patient profile

Patient A is a 20-year-old male residing in Pietermaritzburg, currently a first-year BSc student. He has no prior medical or surgical history but has a six-year history of cannabis abuse, which he ceased four months before the onset of severe psychiatric symptoms. Notably, his mother had been treated for depression ten years earlier.

Case presentation

Over the past five months, significant behavioural changes were observed by the patient’s parents, including reduced socialisation, withdrawal and isolation, poverty of speech and content, aggressive behaviour towards parents, paranoia and distrust of friends, self-talk, hyper-religiosity, and fragmented sleep patterns.

The patient reported auditory hallucinations with a running commentary and command hallucinations. Despite ceasing cannabis use, his symptoms did not improve. In December 2023, severe aggression, violent outbursts, and worsening paranoia necessitated a three-week admission to hospital. The primary diagnosis was paranoid schizophrenia.

Initial treatment

The patient was initially treated with 10mg of olanzapine taken in the evenings, resulting in partial improvement but with severe cognitive blunting, drowsiness, and slowness. He was unable to tolerate the medication and was weaned off over two weeks with family assistance.

Clinical reassessment

By mid-January 2024, the patient’s symptoms re-emerged, including blunted affect, slow and lethargic demeanor, poor eye contact, poverty of speech, and distraction by auditory hallucinations.

Treatment plan

The treatment approach was re-evaluated, considering the patient’s poor response to olanzapine and the need for effective management of both positive and negative symptoms. After discussion with the patient and his family, it was decided to initiate cariprazine, a newer antipsychotic known for its efficacy in treating schizophrenia with a favourable side effect profile.

The patient started on a low dose of cariprazine, 1.5mg in the mornings for five days, followed by an increase to 3mg daily thereafter. This gradual titration aimed to minimise side effects while maximising therapeutic benefits.

Follow-up and outcome

A follow-up assessment on 26 March 2024 revealed significant improvement and remission of psychotic symptoms. The patient reported feeling more engaged with his studies, exhibiting improved communication and social interactions. His parents noted a marked reduction in aggression and paranoia, with a return to previous interests and activities.

Feedback from the patient and his parents highlighted enhanced academic performance, increased spontaneity, and the absence of auditory hallucinations and paranoid thoughts. The treatment with cariprazine was well-tolerated, with minimal adverse effects reported during follow-up visits.

Recommendations

Based on the positive response and remission of symptoms observed with cariprazine, continued treatment at 3mg daily in the morning was recommended. Regular follow-ups every four months were advised to monitor the patient’s progress, adjust medication as necessary, and provide ongoing support.

Concluding remarks

The case of Patient A underscores the complexity of treating paranoid schizophrenia in young adults, particularly in managing both positive and negative symptoms effectively. The initial challenges with olanzapine highlight the variability in individual response to antipsychotic medications and the importance of personalised treatment approaches.

Cariprazine emerged as a valuable therapeutic option, demonstrating significant efficacy in achieving complete remission of symptoms with fewer side effects compared to previous treatments. This case exemplifies the critical role of ongoing clinical assessment, adaptive treatment strategies, and patient-centred care in achieving positive outcomes in schizophrenia management.

Case study #2

Patient profile

Patient B is a 47-year-old male who has been under care since 2019. He initially presented with catatonia and a prior history of schizophrenia. His treatment history included multiple modalities with poor response, characterised by symptoms of paranoia, auditory hallucinations, and a sensation of pressure on the brain.

Case presentation

Initially diagnosed >15-years ago, Patient B’s condition deteriorated over time, marked by recurrent psychotic episodes and episodes of catatonia. Upon presentation in 2019, he exhibited severe catatonia, with a flat affect and mutism, requiring extensive support for basic activities.

Initial treatment

Treatment commenced with ziprasidone 20mg twice daily and clonazepam 0.5mg twice daily to manage his psychotic symptoms and catatonic features. However, the initial pharmacological approach exacerbated his condition, leading to a deterioration in mental state and necessitating hospitalisation in a catatonic state.

Following hospitalisation, the treatment plan was adjusted to olanzapine 10mg orally at night and amisulpride 50mg orally twice daily. This regimen aimed to address both positive and negative symptoms of schizophrenia while improving the patient’s overall functional capacity and reducing catatonic features.

Clinical reassessment

Over the course of three years, Patient B showed gradual improvement in cognitive and psychotic symptoms, though persistent negative symptoms posed ongoing challenges. Despite the therapeutic benefits of olanzapine and amisulpride in managing his condition, the patient experienced significant medication-related side effects, including drowsiness, substantial weight gain, and metabolic complications such as raised cholesterol and pre-diabetes.

Treatment plan

In January 2024, a comprehensive review of Patient B’s treatment regimen and health status prompted discussions with his family and healthcare team regarding the need for optimising therapeutic outcomes while minimising adverse effects. Together, they decided to introduce cariprazine, a novel antipsychotic known for its efficacy in managing schizophrenia symptoms with a potentially lower risk of metabolic side effects.

The treatment transition involved gradually tapering off olanzapine while initiating cariprazine at a low dose. Close monitoring of the patient’s response and side effects guided adjustments in medication dosage and scheduling to ensure optimal therapeutic outcomes.

Follow-up and outcome

By mid-2024, significant improvements were noted in Patient B’s overall health and symptom management. He exhibited a notable reduction in sedation, a 10kg weight loss, and improved metabolic markers, including stabilised blood pressure and cholesterol levels. The patient reported reduced anxiety, improved mood, and enhanced social engagement and functional capacity.

Recommendations

Continued monitoring and adjustment of cariprazine dosage were recommended to maintain stability in symptom management and overall health. Regular follow-up appointments every three months were scheduled to assess treatment efficacy, address any emerging issues, and provide ongoing support to the patient and his family.

Concluding remarks

Patient B’s case highlights the complexities and challenges inherent in managing chronic schizophrenia, particularly in patients with long-standing and treatment-resistant symptoms. The decision to introduce cariprazine represented a pivotal step in optimising therapeutic outcomes while addressing the patient’s persistent medication-related side effects and metabolic complications.

This case highlights the importance of personalised treatment approaches, continuous evaluation of treatment strategies, and collaborative decision-making in achieving positive outcomes in schizophrenia management.